CHORIOCARCINOMA

DIAGNOSIS AND MANAGEMENT

Abeer Tasleem
1-5/2016/131
4th Year MBBS
 Gestational choriocarcinoma

 A malignant neoplasm composed of large sheets of biphasic,

markedly atypical trophoblast without chorionic villi
 Gestational choriocarcinoma may occur subsequent to a molar pregnancy
(50% of instances), an abortion (25%), a normal gestation (22.5%) or an
ectopic pregnancy (2.5%)

 In rare cases an intraplacental choriocarcinoma is diagnosed immediately

following pregnancy from placental pathological examination
 Morphology

 The choriocarcinoma is
classically a soft, fleshy,
yellow-white tumour with
a marked tendency to
form large pale areas of
ischemic necrosis, foci of
cystic softening, and
extensive haemorrhage
 Histopathology

 The classic pattern of choriocarcinoma has been described as

bilaminar, dimorphic, or biphasic.
 Alternating arrangement of mononucleate trophoblastic cells and
syncytiotrophoblastic cells characterizes choriocarcinoma.
 The intermediate trophoblast in choriocarcinoma may show
marked variation in the degree of cytologic atypia.
 Vascular invasion often is prominent.
 Chorionic villi are not a component of choriocarcinoma that
differentiates choriocarcinoma from invasive mole.
 Choriocarcinoma lacks the intrinsic endothelium-lined vascular
channels in the centre of a tumour, making it a unique malignant
solid tumour.
 Tumour spread and staging

1. DIRECT SPREAD : to the parametrium, tubes and ovaries.

2. BLOOD SPREAD : occurs early to distant organs. The

commonest sites are
 1-Lungs(80 %)
 2-Vagina(30 %)
 3-Brain(10 %) and
 4-Liver(10 %).
 FIGO classification

 Stage I Disease confined to uterus.

 Stage II Extends outside of the uterus but is limited to the genital structures
(adnexa ,vagina , broad ligament).
 Stage III Extends to the lungs, with or without known genital tract
involvement.
 Stage IV metastases to other organs ( brain, liver , kidneys, ovaries, bowel)
 CLINICAL FEATURES

 1- Persistent or irregular vaginal bleeding: it is the commonest symptom

occurring after labour, abortion or evacuation of a vesicular mole. Bleeding
can occur within days or months but rarely after 2 years.
 2- Vaginal discharge: which is blood stained and offensive due to ulceration
and infection of the growth .
 3- amenorrhea: may be present due to continuous hCG production.
 4-Dyspnoea and haemoptysis are noticed with lung metastasis.
 5-The appearance of neurological symptoms like hemiplegia, epilepsy,
headache and visual disturbances suggest brain metastasis.
 MANAGEMENT

 INVESTIGATIONS
 (1) Uterine curettage: should be done in every case of persistent or irregular
uterine bleeding after labour, abortion or molar pregnancy. However,
intramural tumour cannot be detected by curettage.
 (2) Serum β-hCG: persistent or rising titres in absence of pregnancy are
indicative of trophoblastic neoplasia.(if the level rises more than 100,000
mIU/ml, it is a risk factor)
 (4) IMAGING: Regardless of the imaging modality used, choriocarcinoma often
appears as a mass enlarging the uterus. Sometimes it manifests as a discrete,
central, infiltrative mass. Its heterogeneous appearance correlates with necrosis
and haemorrhage that characterise these lesions.

 Plain X-ray chest: may show secondaries in the form of

" cannon balls" or "snowstorm" appearance
 Ultrasonography: to detect tumour, cystic ovaries and
exclude remnants of conception.
 CT scan: for lungs, liver, brain and bone.
 Lumbar puncture: to rule out meningitis and also to measure the
hCG level in the CSF.
 Blood studies:
 a- complete blood picture including platelet count.
 b- Renal, liver and thyroid function tests.
 c- Blood group.
 Treatment:

 Chemotherapy is the treatment of choice for choriocarcinoma.

 METHOTREXATE is the drug of choice.(this drug interferes
with the formation of nucleic acid and mitosis in the malignant
cells and thereby arrests the growth).
 In low risk patients-single drug i.e.methotrexate is given.
 If the patient has jaundice then actinomycin D should be given.
SINGLE DRUG REGIMEN IN LOW RISK CASES
 MULTIDRUG THERAPY

 Multidrug therapy used most commonly is Bagshaw regime consisting of:-

 E=ETOPOSIDE (100 mg/m2 IV infusion in saline over 30 min).
 M=METHOTREXATE (100mg/m2 IV infusion over 12 hours)
 A=ACTINOMYCIN D(0.5 mg IV stat)
 C=CYCLOPHOSPHAMIDE (600 mg IV in saline)
 O=VINCRISTINE(ONCOVIN) (10 mg/IV stat)
 High risk patients and patients with stage 4 are to be treated with combination
chemotherapy-EMACO.
 This course is repeated every 3 weeks.
 ROLE OF SURGERY

 1. TOTAL HYSTERECTOMY is done if required in choriocarcinoma.The

ovaries are not usually involved and if involved, can be effectively cured
with postoperative chemotherapy, hence bilateral salpingoopherectomy is
not done.
 2. LUNG RESECTION
 3. CRANIOTOMY
 PROGNOSIS

 The cure rate is almost up to 100 percent in low risk and about 70 percent in
high risk metastatic groups.

 Follow up is mandatory for all patients at least for 2 years.

 Serum hCG is measured weekly until it is negative for three consecutive

weeks. Thereafter it is measured monthly for 6 months and 6 months
thereafter for life.
Thank you.